HUGE GOITER AND AIRWAY MANAGEMENT

Transcription

1 HUGE GOITER AND AIRWAY MANAGEMENT

2 1. Introduction 2. Airway challenges in goiter 3. ASA Difficult airway algorithm 4. Different methods to anaesthetic airway management 5. Flexible fiberoptic bronchoscopy 6. How we did it in our OT????

3 The normal thyroid gland is impalpable. The term goiter is used to describe generalised enlargement of the thyroid gland. It was coined from the Latin guttur = the throat

4 Thyroidectomy is the MC endocrine procedure being carried out. The anesthesiologist has to face difficulty while administering anesthesia for a large thyroid swelling. Anticipated difficult airway due to pressure effects of enlarged thyroid gland further adds to the anesthetic challenges. The challenging scenarios can be encountered at any stage during airway intubation or extubation or postoperative period.

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6 History Physical Examination

7 1.Elicitation of history should include symptoms and signs related to hyperthyroidism, hypothyroidism and co morbid medical diseases. 2.History should also include difficulties encountered during normal breathing and respiration such as dyspnea, orthopnea, dysphagia, stridor or horseness of voice breathlessness on assuming supine position.

8 Dr. Binnions Lemon Law: An easy way to remember multiple tests Look externally. Evaluate the rule. Mallampati score Obstruction Neck mobility.

9 Nose- DNS, Polyp Teeth-Buck Teeth Receding Jaw (Dentures) Burns Short Muscular neck Obesity or very small. Facial Trauma Macroglossia

10 ü 3 fingers fit in mouth ü 3 fingers fit from mentum to hyoid cartilage ü 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage

11 M-Mallampati Score (Samsoon and Young s modification) Grade 1&2 : Easy laryngoscopic view of glottis Grade 3&4 : Difficult & impossible view of glottis Class-1 Class-11 Class-111 Class-1V soft palate, fauces; uvula, anterior and the posterior pillars. soft palate, fauces and uvula soft palate and base of uvula Only hard palate

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14 Judged with: 1.Jaw putrusion (Subluxation) 2.Upper lip bite test (ULBT) 3.Hyomental distance: distance between mentum and hyoid bone. Gr I->6 Cm, GrII-4-6 cm GrIII-< 4 cm Gr III difficult intubation 4.Thyromental Distance >6.5 cm Normal <6 cm difficult intubation may be possible. 5.Sternomental Distance >12.5cm normal

15 Estimates the angle traversed by the occluded surface of the upper teeth Grade I --- > 35 Grade II Grade III Grade IV -- < 12 15

16 Class I: the vocal cords are visible Class II the vocals cords are only partly visible Class III only the epiglottis is seen Class IV the epiglottis cannot be seen. grade 3,4 -> risk for difficult intubation

17 ASA defines Difficult airway as Situation where a conventionally trained anesthesiologist experiences difficulty with mask ventilation, endotracheal intubation or both

18 B-BeardHiding? Bad seal O-Obesity BMI > 26-30kg/mt2 N- NoTeeth E-elderly >55yrs S-Snoring and

19 BANG B- Bleeding tendency A- Agitated patient N-Neck scarring or Flexion deformity G- Growth or vascular abnormality in the region of surgical deformity

20 CVS Resp system. CNS Vital signs; lab tests CBP,Sr.ele,bu/sc,Sr.cal, Lft, Ct/bt, CUE, Ecg, 2decho

21 Thyroid Functional test TSH, T3, T4 Chest and thoracic inlet radiography Neck X-ray Ultrasound scanning Fine-needle aspiration cytology Indirect laryngoscopy ( idl): IDL is done preoperatively to detect any invovlement of the vocal cords Computerised tomography, magnetic resonance imaging

22 Pt should be euthyroid state before surgery Informed valid written consent. Nothing by mouth for 6 hours. Tab.alprazolam 0.25 mg and tab.ranitidine 150 mg given at night before day of surgery Pt should continue any medication if he is ON eg. anti HTN and antithyroid drugs on the day of surgery

23 a. O2 source checked b. Difficult Airway Trolley Tracheal tubes Tracheal tube guides Laryngeal Mask Airway Non-invasive/minimally invasive equipments airways- OPA,NPA Surgical Airway Fiberoptic Bronchoscope Drugs: all emergency drugs Monitors: pulse oximetry etco2,ecg,nibp

24 Inj.Glycopyrronium 0.2mg/iv given to minimise the airway secretions. Antiemetic drug - inj. Ondansetron 4 mg/iv Sedatives is omitted or given in small doses. If required to alley anxiety Inj. Midazolam 1mg/ iv is given

25 Intubation- can be done under 1. Awakea. Nerve block b. Topical anesthesia Spray As You Go technique 2.Asleep/Induced state

26 a.nerve Block i.glossopharyngeal block ii.superior laryngeal block iii.trans tracheal block i.glossopharyngeal block There are two way to approach: 1.Intra-oral need enough mouth opening 2.Peristyloid require the ability to distinguish the bony landmarks

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28 ii.superior laryngeal block Patient position is supine with neck extended. The greater cornu of the hyoid bone is palpated and identified just below the angle of the mandible and by tracing upwards from the posterolateral surface of the thyroid cartilage. The hyoid bone is held between the index and thumb fingers of the operator and firm pressure is applied to displace it toward the side to be blocked. After negative aspiration for air and blood, 2-3 ml of 2% lignocaine is injected. iii.trans tracheal block placed pt insupine with neck extended The cricothyroid membrane can be felt in the mid line between in the mid line of the thyroid prominence and the cricoid cartilage. Aspiration is done, and, when air is aspirated, the local anesthetic is 4ml of inj.of 2 % lignocaine is injected.

29 ANAESTHETISING THE AIRWAY ANAESTHETISING THE AIRWAY Nasal Cavity. Cotton-tipped swabs soaked in 4% lidocaine is placed superiorly and posteriorly in the nasopharynx. Then wait for 5-10min minutes to block the branches of the ethmoidal and trigeminal nerves Nebulise 2ml 4% Lignocaine Mouth and Oropharynx Anaesthesia of posterior one third and posterior oropharyngeal wall( gag reflex). Lidocaine (lignocaine 4%; 4mL) can be nebulized. Viscous lignocaine 2% around 2-4 ml can be gargling applying a 4%l ignocaine soaked swab or spray with 10% Lidocaine (lignocaine) larynx below the vocal cords, and tracheo-bronchial tree, 4% Lignocaine in 1 ml aliquots to anaesthetise to larynx below the vocal cords, and tracheo-bronchial tree, using: Spray as you go technique during endoscopy

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33 Explain to the pt regarding the procedure. 1. The reasons for proceeding with an awake fiberoptic intubation 2. The potential complications 3. The type of airway anesthesia that will be provided 4. Possible alternatives to the proposed.

34 Premedication is given min before the procedure Apply anaesthesia to the airway- 2 methods 1.Nasal packing, orapharynx with nebulisation of lidocaine or gagrling can be done preoperative area. 2.Nr blocks- Intra operatively Intraoperatively, I v line secured and monitors are connected. Pt position a. supine- endoscopist is at the head of table b.sitting- endoscopist faces the pt. Preoxygenation a. nasal cannula in spontaneously breathing pt b.o2 flow through the suction port Procedure can be done orally or nasally

35 Nasal is prefered to avoid biting to the scope Introduce the fibrescope through the nostril Steer the fibrescope into the oropharynx, Steer the fibrescope into the oropharynx, Once in the oropharynx, visualization of the epiglott is the st landmark. Advance the fibrescope into the laryngeal opening using Spray As You Go Technique. Advance the fibrescope until it enters the subglottic space, visualization of the trachea, 2nd landmark. Advance the fibrescope again into the trachea, identifying the carina, 3rd landmark Keep the carina in the field of vision at all times to prevent dislocation of the fibrescope out of the larynx into the oesophagus Remove the fibrescope maintaining the ETT in place, with the tip at 3-5cm above the carina. Fix the ETT in place and connect to the anaesthetic breathing circuit Confirm the ETT position by capnography, auscultation of bilateral air entry, observation of bilateral chest movement and misting of the tube, 5. Induce the patient using appropriate anaesthetic agents (intravenous, inhalational, neuromuscular blockers), and inflate the ETT cuff.

36 Maintain spontaneous ventilation Maintain esophageal tone ( aspiration) Able to protect if reflux occurs Most Versatile Tool Available for Difficult Intubation Optical Elements are Small Visualization Below the Cords Awake Intubation Disadv Unique Skillset Lens Contamination Cost

37 Allergy to local anaesthetic agents Infection/contamination of the upper airway blood, friable tumour, open abscess Grossly distorted anatomy Fractured base of skull (CI to nasal route) Penetrating eye injuries Patient refusal or uncooperative patient

38 1. Inability to advance FOB into Trachea 2. Inablilty to advance Ett into trachea from FOB 3. Inability to remove FOB.

39 3. ASA Difficult airway algorithm

40 Anticipated DA, so awake fiberoptic intubation is technique of choice to this pt. So,Difficult airway trolley kept ready Pt explained about the procedure Premedicated with inj. Glyco, inj. Ondansetron Preoxygenation given adequately As anatomy of neck is distorted Nr block technique for awake intubation is precluded. We followed spraying of L.A. as we go technique with 10% lidocaine spray. AFOI is tried and failed due to obstruction with soft tissue mass protruding from the right side With difficult we managed to negosiate the Ett by direct laryngoscope with aid of bougie

41 Pt the induced with Inj. Thiopentone 5mg/kg Long acting muscle relexant inj Vecuronium 0.1mg/kg is given as loading dose Maintenance of anaesthesia: O2+N20, Volatile inhalational agents Opioids, Muscle relaxants

42 After the conclusion of surgery, NMB is reversed by Inj. Neostigmine + inj.glyco Extubation done electively.

43 1.Immediate Laryngospasm, post op laryngral oedema Tracheomalacia causing airway collapse, Nr injury- B/L RLN or SLN 2.Late phase Hematoma, hypocalcemia

44 Thank u